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Positioning for Function: The Trunk and Extremities

Positioning for Function: The Trunk and Extremities
Michelle Lange, OTR, ABDA, ATP/SMS
March 24, 2021

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Editor’s note: This text-based course is a transcript of the webinar, Positioning for Function: The Trunk and Extremities, presented by Michelle Lange, OTR, ABDA, ATP/SMS.Learning OutcomesAfter this course, participants will be able to identify kyphosis and seating interventions to address this concern.After this course, participants will be able to identify lateral scoliosis and trunk rotation and seating interventions to address these concerns.After this course, participants will be able to identify lordosis and seating interventions to address this concern.After this course, participants will be able to recognize hip, knee, ankle, and foot positioning challenges and seating interventions to address these concerns.After this course, participants will be able to recognize upper extremity positioning challenges and seating interventions to address these concerns.IntroductionI appreciate the time that you are taking out of your hectic schedules. I hope this information is helpful to you and especially to the clients that you serve. Today, we will be talking about wheelchair seating and focus on the areas of the trunk and the lower and upper extremities. I have other seating-related courses in the occupationaltherapy.com library like "Positioning the Pelvis." We often start with a mat examination. I provide education for Stealth Products, and they do make some seating components. However, I will be presenting this information as unbiased as possible. This learning event is not focused on a specific product or service but a variety of interventions.TrunkWhat We Will Be CoveringAchieving and maintaining a neutral and upright trunkKyphosisLordosisRotationLateral ScoliosisCombined spinal asymmetriesWe are going to talk about achieving and maintaining a neutral and upright trunk. Figure 1 shows our spinal column.Figure 1. Spinal column.We will specifically look at kyphosis, lordosis, rotation, lateral scoliosis, and a combination of these asymmetries.Why Is This Important?The position of the trunk, and subsequently the head, is very dependent on the position of the pelvisMaintaining an upright trunk requires intrinsic muscle strength, balance, and stabilityIf a client lacks intrinsic control, extrinsic supports are requiredGravity has a profound influence on the trunkWe are supposed to sit with an upright trunk. Not only would our grandmas be proud of us, but there are also other clinical implications. The trunk is very dependent on our pelvis's position, and the head is very dependent upon the trunk position.Vertebrae are all stacked on top of each other between the pelvis and the head, and it must have adequate support. Maintaining an upright trunk for most of us requires a certain degree of muscle work. We have intrinsic muscle control, which allows us to balance our flexors, extensors, and lateral muscles to be in an upright and aligned position. If the client lacks this intrinsic control due to muscle weakness, paralysis, or abnormal muscle tone, extrinsic supports may be required. We need to remember that gravity has a profound influence on our bodies. As I get older, I am noticing that more and more, particularly in the trunk. Thus, we need to provide adequate support.Positioning StrategiesNot a cookbook approachCan’t really look at challenges in isolationAlways keep in mind the possible causes and your goalsGoals can be used as justifications for fundingPositioning Chartwww.atilange.com under ResourcesSee handoutsInterventions are not as simple as opening up a cookbook. We cannot look at these challenges in isolation, but we have to look at the entire client. For this presentation, we are going to tease out some of these challenges and address them.As we look at these particular seating challenges, like kyphosis, we need to keep in mind what might be causing an issue for a client and our goals. If we do not know what is causing a particular challenge, we may choose the wrong intervention. It is vital to dig down and figure out what is going on.It is important to know why we are doing what we are doing so that the goals become our outcomes and the justification in our letter of medical necessity. Why are we fixing what we are fixing? Your handouts are a positioning chart and a PDF of this PowerPoint. The positioning chart is also available on my website under resources. It is meant to be a reference. You can look back at it either throughout the session or refer to it afterward.A Word About AssessmentWe are not going into Seating Assessment todayWe are jumping into common seating challenges and interventionsBut… don’t forget that Mat Evaluation!I do have a course on the mat assessment that I would encourage you to check out. We are jumping right into the seating challenges for this course, but the mat evaluation, as noted in Figure 2, is so important.Figure 2. Example of a mat evaluation.We need to see what the client looks like, supine with gravity eliminated and sitting on the edge of the mat table. I like to use my body to provide adequate support to see how the client looks against gravity. During this assessment, I can see what a client needs as far as support and angles.Anatomy ReviewTrunkSpineCervical C1-C7Thoracic T1-T12Lumbar L1-L5Rib cageMusclesAttached to the pelvisAttached to the skullOn the spine, there are three distinct zones: the cervical, thoracic, and lumbar vertebrae.Figure 3. A rear view of the spinal cord.We can see asymmetries and a lack of flexibility in any of those segments. The rib cage is attached to the thoracic vertebrae. The muscles pull on all those vertebrae and impact the rib cage. These are also connected to the pelvis and the skull. Again, it is a little tricky to look at the spine without considering the position of the pelvis and the head.Key multi-joint muscles that impact trunk positionHip Flexors – psoas (zo-is) majorThis muscle attaches to the femur at one end and all the lumbar and lowest thoracic vertebrae at the otherFlexes and externally rotates the hip and stabilizes the lumbar spine with the abdominalsIf the range is limited, the psoas will pull the pelvis into an anterior tilt and the spine into lordosis. External rotation may also be present. Solution:Allow slight external rotationStabilize pelvisDetermine optimal seat to back angle on mat examSome key muscles impact the position of the trunk. What is tricky is that some of them are multi-joint muscles crossing more than one joint. This means that we have to consider both areas that the muscle crosses and how...

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michelle lange

Michelle Lange, OTR, ABDA, ATP/SMS

Michelle is an occupational therapist with over 30 years of experience and has been in private practice, Access to Independence, for over 15 years. She is a well-respected lecturer, both nationally and internationally and has authored numerous texts, chapters, and articles. She is the co-editor of Seating and Wheeled Mobility: a clinical resource guide, editor of Fundamentals in Assistive Technology, 4th ed., NRRTS Continuing Education Curriculum Coordinator and Clinical Editor of NRRTS Directions magazine. Michelle is a RESNA Fellow and member of the Clinician Task Force. Michelle is a certified ATP, certified SMS, and is a Senior Disability Analyst of the ABDA.

 



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This course will present common trunk asymmetries seen in wheelchair seating with suggested strategies to address each challenge. Providing as neutral a trunk position as possible improves overall posture, stability, and function. This course will then systematically address potential upper and lower extremity positioning challenges with suggested interventions. By specifically positioning the extremities, the seating system provides stability, function and even protection from injury. This course is directly related to the practice of physical therapy and is therefore appropriate for the PT/PTA.

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